Fairness in Olympic sports: How can we control the increasing complexity of doping use in high performance sports?

With the Rio Olympics just a few months past, we remember the excitement, the incredible performances, and the controversies. As happens so often, the Olympic Games focus attention not only on athletic achievements but also on how athletes may reach ever-increasing levels of performance. Doping, medical doping exemptions, and the ban of the Russian team for state-sponsored organized doping of its athletes dominated the discussions.

After the Rio Olympics, it was revealed that many prominent athletes had health-related drug exemptions and thus were allowed to use medication containing substances banned by the World Anti-Doping Agency (WADA). Particularly, exemptions for asthma medication and attention deficit hyperactivity disorder came under scrutiny. The number of exemptions became suspicious when it was revealed that in certain sports (e.g., cycling and swimming), the percentage of athletes suffering from asthma is much greater than in the average population. Asthma medications, such as salbutamol and terbutaline, are said to be not performance enhancing, but they will increase performance in asthmatic athletes by up to 10%.¹ However, it is impossible to know what the normal performance level of an asthma sufferer would be were she or he free of asthma. This argument is reminiscent of the discussions surrounding Oscar Pistorius, the double-amputee “blade runner” who participated in the London Olympics, and scientists' disagreements about whether Mr. Pistorius had an unfair advantage running with his specialized lower limb prostheses. Of course, we will never know, because nobody can determine with certainty how fast Mr. Pistorius could have run the 400 m sprint had he had his “normal” legs. One might argue that when a drug contains banned substances, there should be no medical exemptions. Asthma sufferers should be allowed to use banned substances but should be categorized as Paralympic athletes and compete against each other in a separate competition. In swimming and cycling, approximately 40% of all Olympic athletes would fall into this category, making winning in the asthma category as competitive as the regular Olympic swimming and cycling competitions.

Another drug that has received intense scrutiny and press is meldonium, which can be purchased under the trade name Mildronate. Meldonium was developed in the 1970s at the Latvian Institute of Organic Synthesis in the former Soviet Union. It is primarily used as a treatment against coronary artery diseases and has seen widespread use among Eastern European athletes. WADA put meldonium on the list of banned substances on January 1, 2016, and subsequently several high-profile athletes were caught using the substance. Prominently, in early March of 2016, the international tennis superstar Maria Sharapova announced that she had failed a drug test at the Australian Open Tennis Tournament. Meldonium had been found in her system, and she admitted of having used meldonium for the past 10 years for a variety of health problems. She argued that she was not aware that meldonium had been put on the banned substance list. Nevertheless, she was suspended by the International Tennis Federation for a 2-year period (a suspension that has been appealed).

In the Journal of Sport and Health Science, Lippi and Mattiuzzi² give a detailed account of the health benefits of meldonium and its possible benefits on athletic performance. They argue that meldonium has no proven effect on performance in elite athletes. However, meldonium's mechanism of action suggests that it might enhance endurance and might allow for faster recovery from intense workouts.

The world of professional and Olympic sports has become big business, and today's superstar athletes have contracts worth millions of dollars. The prestige associated with an Olympic gold medal, and the possibilities for converting success in sport into a lucrative career, make it increasingly difficult to keep sports clean. I believe that the issue of medical exemptions and the punishment of athletes for failed drug testing need to be re-evaluated based on strong philosophical and ethical grounding. The current system is a patchwork with good intentions, but it is not fair and not workable in the long term. If we want to preserve “clean” competitions, WADA needs to rethink the current system and policies from their very foundations.